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Simulators Teach DoD Medical Students How to Save Lives

FOREST GLEN, Md., Nov. 17, 2000  Army Dr. (Col.) Christoph Kaufmann said the goal of DoD's new National Capital Area Medical Simulation Center here can be summed up in three words: "to save lives."

Navy Ensign Lisa A. Peterson, 25, checks the throat of a mannequin patient simulator with the help of Army 2nd Lt. Matthew Laudie. Air Force 2nd Lt. Jared Chugg watches the procedure. The three are training in the mock operating room of a virtual reality lab at the National Capital Area Medical Simulation Center, Walter Reed Army Medical Center Annex, in Forest Glen, Md. They're third- year medical students of the Uniformed Services University of the Health Sciences in nearby Bethesda, Md. Photo by Rudi Williams. (Click photo for screen-resolution image);high-resolution image available.

Surgical director Kaufmann said several medical schools have been using simulation centers with patient "actors" for about 10 years, but he called the DoD center unique. What's new, he noted, is that three state-of-the-art components are under one roof -- virtual reality technology, computerized mannequin simulators and the patient "actors."

He said thousands of Americans die every year because of medical errors. Students and other medical professionals who train at the center will make fewer mistakes, he said.

"We can push the student to the point of failure. We can let the student make that fatal mistake," the surgeon said. "Lessons learned through failure are not forgotten. When you make a mistake, you remember.

"Simulators allow us to train at the fringes of medical treatment," Kaufmann pointed out. "Students can be permitted to take risks they simply wouldn't be allowed to take with real patients."

The Uniformed Services University of the Health Sciences at the National Naval Medical Center in Bethesda, Md., opened the center in September 1999. Located at Walter Reed Army Medical Center Annex at Forest Glen, just north of downtown Silver Spring, Md., the facility will train more than 500 medical students from all the services each year.

The school's medical students are not the only ones trained at the center. Nurses, nurse practitioners, residents, fellows, and even faculty have made use of simulation center resources.

Students learning to be doctors rotate through various emergency medical scenarios at the center. For example, the budding doctors may walk into a clinical exam room and find a patient "actor" curled up on the exam table simulating a specific disease state. The student has to diagnose and prescribe treatment for the condition. Their skills are also tested in a mock operating room and a virtual reality lab.

"We can train on the fringes of medicine using this operating room with the digitized mannequin and virtual reality tools," Kaufmann said. "We can push our medical students and residents beyond what would be otherwise safe -- without hurting real patients."

"This experience has been great in teaching us some basic skills that we'll need in the hospital," Third-year medical student Navy Ensign Lisa Peterson said. "And we're learning in a stress-free environment!"

Army 2nd Lt. Katrina Walters said training on the computerized mannequin and other equipment, where mistakes don't threaten lives, will be valuable when diagnosing and treating real patients. "The opportunity to have another physician watch and critique your technique is valuable," she said.

The sophisticated teaching tools enable the staff to teach new procedures and ensure that students see all the procedures and all the anatomy that exists, Kaufmann said. Another major use of the center is the instruction of readiness skills and focused predeployment training for wartime, peacekeeping and humanitarian missions.

The National Board of Medical Examiners has adopted the use of patient "actors", so that by 2002, they'll be used to test every graduating medical student's skills in diagnosing basic medical problems, he said. The virtual reality lab and the operating room are tools that allow instructors to deviate from traditional ways of teaching medical specialties. For example, he said, students over the centuries learned surgery through an apprenticeship.

"Students would attach themselves to master surgeons and participate and observe for a number of years until the masters felt they were ready to practice on their own," he noted. "Today, we still don't have hands-on skills assessment for students graduating from surgery training programs." Simulators will change that.

"We can, in the very near future, ensure that a graduating surgeon will be able to pass a standardized skills test," he said. "I expect that before I stop doing surgery, I'll be required to recertify my surgical skills on a simulator, because the technology is growing so rapidly."

Simulators are a big improvement in teaching method because students today are trained by opportunity, the colonel said. "We're only exposed to what we're exposed to," he noted. "Using simulators helps us ensure that all the breadth of the anatomy and surgical procedures are being taught during the course of a residency." Further, the patients' interests rightfully come first and medical education comes second, he added.

"We have to keep the student from going across the threshold of hurting the patient," Kaufmann said.

He said shorter hospital stays nowadays hamper traditional training techniques. For example, he said, when a patient was hospitalized for several days, everyone -- medical students, interns, residents and the attending physician -- could visit. They would talk to the patient, do a medical history of the patient's condition, perform a physical examination and participate in the patient's care.

"Today, one of our obstacles in medicine is that patients spend much less time in the hospital," he said. "Same-day, in-and-out surgery accounts for about 50 percent of operations in this country. So there is no continued ability for students to have the exposure to patients they had 10 or 20 years ago. So we have to train just as many doctors with less patient contact time. Simulators will be helpful with that."

Simulation is still in its infancy, "about at the Wright Brothers airplane stage," Kaufmann said. "But there are some sophisticated simulators that are used in sewing together blood vessels or intestines." Some of the simulators today provide a realistic picture of the anatomy that students can view in either 3-D or on a 2-D monitor, like a TV screen.

"The TV monitor-type virtual reality application is useful for teaching medical students, starting in IV (intravenous injection) and diagnostic procedures," Kaufmann said. "We've developed a couple of these simulators here."

He said the center has 12 clinical exam rooms for simulated patients, a computer lab with 16 computers for distance learning and for high-stakes education and high-stakes testing, such as the national board examination.

"The tools we have today require the individual to be present here to use them," Kaufmann said. "In the future, we see these applications being used with distance learning technology."

Dr. David Wherry, a surgeon at the Uniformed Services University of the Health Sciences, teaches Navy Ensign Hugh Dainer, 27, how to tie surgical knots in the suture lab at the National Capital Area Medical Simulation Center, Walter Reed Army Medical Center Annex, in Forest Glen, Md. Photo by Rudi Williams.Download screen-resolutionDownload high-resolution

Air Force 2nd Lt. Christian Smith, tries to diagnose the condition of a patient -- an actor going by the stage name "James Latchford" -- at the National Capital Area Medical Simulation Center, Walter Reed Army Medical Center Annex, in Forest Glen, Md. Photo by Rudi Williams.Download screen-resolutionDownload high-resolution

Army Dr. (Col.) Christoph Kaufmann explains a surgical procedure to third-year students at DoD's new National Capital Area Military Medical Simulation Center, Walter Reed Army Medical Center Annex, in Forest Glen, Md. Kaufmann summed up the goal of the center in three words: "to save lives." The students attend the Uniformed Services University of the Health Sciences in Bethesda, Md. Photo by Rudi Williams.Download screen-resolutionDownload high-resolution

Using a mannequin "patient," Air Force Dr. (Lt. Col.) Mark Bowyer shows medical students how to insert a tube in a patient's chest to allow air to escape. Training is at the National Capital Area Medical Simulation Center, Walter Reed Army Medical Center Annex, in Forest Glen, Md. Assisting Bowyer is medical student Army 2nd Lt. Katrina Walters. Observers are Navy Ensign Hugh Dainer (center) and Navy Ensign Dirk Warren. Photo by Rudi Williams.Download screen-resolutionDownload high-resolution